HYPERTENSION (Blood Pressure in Childhood) Starship Children’s Health Clinical Guideline

Transcription

Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
HYPERTENSION (Blood Pressure in Childhood)
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Measurement of Blood Pressure
Normal Blood Pressure
When should BP be measured?
Definition of Hypertension
Signs & Symptoms
Causes of Transient Hypertension
Causes of Sustained Hypertension
Investigation of the Hypertensive Child
Hypertensive Urgency
Hypertensive Emergency
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Management of the Hypertensive
Emergency
Management of Primary Hypertension
Recommended Reading
Appendix 1 – Tables of Blood Pressure
Levels for Age & Height
Appendix 2 – Neonatal BP Values
Appendix 3 - Oral antihypertensive drugs
for management of hypertension in
children
References
An elevated blood pressure level in childhood can predict an increased cardiovascular risk in adult
life. The increasing prevalence of childhood obesity necessitates regular surveillance of blood
pressure to detect abnormal blood pressure and hence increased cardiovascular risk. Identifying
hypertension in children allows for treatment, assessment of target organ damage and
investigation of aetiology.
Measurement of Blood Pressure
Devices
The most common methods are:
(1) Aneroid sphygmomanometry (manual blood pressure)
(2) Oscillometry using automated devices such as DINAMAP (Critikon).
Mercury manometers are no longer in routine clinical use. Aneroid devices are not as accurate as
mercury manometers and require regular calibration. Oscillometry detects arterial pulsations by
transducer. The mean arterial pressure is measured, and systolic and diastolic recordings are
calculated from a mathematical formula. There is good agreement between DINAMAP readings
and blood pressures obtained by invasive central aortic measurements. DINAMAP values are
generally 6-7 mm Hg higher for systolic and 2-4 mm Hg lower for diastolic. DINAMAP recordings
have the potential for less variability, less error and greater reproducibility.
DINAMAP
measurements may be inaccurate in low birth weight or preterm infants where it may overestimate
BP. Ambulatory blood pressure monitoring is also available for investigation of those with
suspected hypertension, those at risk of developing hypertension or difficult to mange blood
pressure.
Appropriate Cuff Size
This refers to the size of the inflatable bladder. The correct size is based on the diameter
(thickness) of the arm, not the age of the child. Length is not as important. The widest cuff that can
be applied to the arm should be used, with the bladder covering at least two thirds of the upper
arm, and the length of the cuff should completely encircle the arm. Small cuffs result in a spuriously
high BP, whereas the risk of a spuriously low blood pressure from too large a cuff is minimal. It is
better to use a cuff which too large than one that is too small.
Author:
Editor:
Dr William Wong
Dr Raewyn Gavin
Hypertension (Blood Pressure in Childhood)
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The cuff should be at heart level. Blood pressure should be measured on the arm only. There are
no significant differences in BP between supine and erect as long as the cuff is at heart level and
the child is volume replete.
Technique
The child should be seated in a quiet room for at least 5 minutes before taking the blood pressure.
The right arm is preferred for consistency and because of the possibility of aortic coarctation
(falsely low recording in the left arm.) Blood pressure should not be measured routinely on the leg
as this may result in a false high reading.
Definition of Systolic and Diastolic BP
Systolic BP = 1st Korotkoff sound (K1). Diastolic BP = K5 in young children, K4 in adolescents.
Use K4 (muffling of the sounds) in young children if K5 is very low, in which case record both.
Variables Affecting the Measurement of BP
Several variables can affect BP measurement including:
 Patient behaviour (anxiety, cooperation)
 Medications (beta-agonists, steroids)
 Observer variability (detection of Korotkoff sounds)
 Cuff size (as above).
There are significant variations in published normal measurements due to these differences.
Normal Blood Pressure
Current normative data is based on auscultation and there is no normative blood pressure data
that is based on recordings measured from oscillometric devices.
There is limited data available on infants and young children. There is no significant difference
between sexes in the first 5 years of life. Blood pressures rise gradually from 2 to 5 yrs of age, at a
rate of approximately 1 mm Hg per year, and at a rate of 1.5 mm Hg per year from 7 to 11 years of
age. In older children a wide variation of "normal values" are reported. Approximately 40% of the
variability of BP in children is related to height, weight, triceps skin fold thickness, and arm
circumference. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood
Pressure in Children and Adolescents presents new data and the reader is advised to consult this
extensive report.
See Appendix for BP tables
When Should BP be Measured?
It should be an integral part of the physical examination. Measure it 4 to 5 times in early school
age, after which only children with "high" BP (>75th centile) need following. Measure BP more often
in "high risk" children: IDDM, obesity, hyper-lipoproteinemia (child or parent), periodically high BP,
risk factors in a parent (severe hypertension, early stroke or MI), renal disease, syndromes known
to be associated with hypertension.
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Dr Raewyn Gavin
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Definition of Hypertension
A single moderately elevated measurement does not indicate hypertension. There must be
repeated evaluation under basal conditions, over time. A very high blood pressure measurement
requires urgent evaluation and treatment.
The 4th report definitions are as follows:
Pre hypertension
(previously borderline hypertension) is defined as an average SBP and/or
average DBP between 90th and 95th centile. This group is considered at
increased risk for hypertension.
Hypertension
Average systolic and/or diastolic BP > 95th centile for age, sex and height
obtained on at least 3 occasions.
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Stage 1 hypertension average SBP ± DBP 95 to 99% for age and sex with no end organ
damage.
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Stage 2 hypertension: average SBP ± DBP ³ 99% ± end organ damage.
A patient with BP levels >95th centile in a clinic setting, who is normotensive outside the clinic
setting has “white coat” hypertension
If a statistical definition of hypertension is used, then potentially 5% of children have hypertension,
a prevalence which is not supported in clinical studies where 1-2% of children have hypertension.
Signs and Symptoms of Hypertension
The signs and symptoms of hypertension vary enormously. The underlying disease causing
hypertension may also have symptoms.
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Neonates: Respiratory distress, sweating, irritability, pallor/cyanosis, failure to thrive, sepsislike picture, cardiac failure, apnoea, vomiting, seizures
Older children: Fatigue, encephalopathy, headache, heart murmur, blurred vision, anorexia,
nausea, epistaxis, weakness (facial palsy), weight loss / gain, polydipsia / polyuria, tiredness,
enuresis, abdominal pain, haematuria, short stature. Acute hypertension in older children may
be heralded by, Bell’s palsy, headaches, seizures, sudden visual loss, epistaxis or abdominal
pain.
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Editor:
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Dr Raewyn Gavin
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Causes of Transient Hypertension
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Acute glomerulonephritis, Henoch-Schonlein nephritis, haemolytic uraemic syndrome, other
causes of acute renal failure.
Post urologic surgery or renal transplantation.
Acute hypovolaemia (nephrotic relapse, burns, adrenal + GI saline depletion).
Acute hypervolaemia (excessive administration of blood, saline or plasma).
CNS disease (tumour, infection, seizures, injury).
Guillain-Barre syndrome.
Hypercalcaemia.
Lead Poisoning.
Medications (steroids, sympathomimetics, contraceptive pill).
Causes of Sustained Hypertension
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Coarctation of aorta.
Renin-dependent hypertension:
o Renovascular
o Renal parenchymal: coarse renal scarring (reflux nephropathy, obstructive uropathy,
neuropathic bladder), glomerulonephritis, polycystic kidney disease, hemolytic uraemic
syndrome.
o Renal tumour.
o Catecholamine-excess hypertension (pheochromocytoma, neuroblastoma).
Corticosteroid excess (Congenital adrenal hyperplasia, Cushing’s or Conn’s syndrome).
Essential hypertension.
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Editor:
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Dr Raewyn Gavin
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Investigation of the Hypertensive Child
The level and urgency of investigation depend on the rapidity of onset, severity, and age. The
younger the child, and the more severe the hypertension, the more likely there is an underlying
cause. Initial investigation is focussed on the kidneys, as 80% have a renal abnormality. You must
also search for evidence of end organ damage.
First line Investigations
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Medical history (symptoms of hypertension, medications, trauma, growth)
Family history (renal or CVS disease, endocrine tumours, phakomatoses)
Examination
- Mental state and coma score (Encephalopathy).
- Optic Fundi (papillodema, haemorrhage, exudates).
- Visual acuity and pupillary responses (Visual impairment).
- Tone, power and reflexes (Hemiparesis, Bell’s palsy).
- Tachycardia, gallop rhythm, hepatomegaly, crackles(Congestive heart failure).
- Abdominal masses or bruits (Renal enlargement ,R Art stenosis).
- Signs of virilisation or cushingoid habitus (CAH, Cushing’s syndrome).
- Skin (neurofibromatosis)
Urinalysis (urinary sediment, microscopy and culture)
Cardiac investigations (CXR, ECG, echocardiogram)
Renal function (U&E, creatinine, chloride, acid base, FBC, GFR estimation)
Renal Ultrasound including Doppler study of renal arteries
Second Line Investigations
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Further imaging of the urinary tract (DMSA scan, MCU)
Imaging of renal vasculature (CT angiography or MR. Angiography)
Urine catecholamines
Plasma renin and aldosterone
ESR and ANA
Other Investigations (on advice from renal team)
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Renal vein renin sampling, arteriography, isotope scan for pheochromocytoma
NOTE: A normal ECG does not exclude left ventricular hypertrophy
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Hypertensive urgency
Hypertensive urgency is defined as a significant elevation of blood pressure without evidence of
end organ injury. Patients are symptomatic with headaches or nausea but without end organ
involvement. The patient is clinically stable.
Treatment with oral hypotensive agents is indicated if BP is above the 99th centile for age, height
and gender, on three occasions 30 minutes apart. See Appendix for BP tables.
The choice of agents are:
Beta blockers (labetolol, atentolol)
Vasodilators (isradipine, felodipine, amlodipine, minoxidil)
Angiotensin converting enzyme inhibitors (captopril, lisinopril, enalapril)
Diuretic if volume overload is evident.
Sublingual nifedipine is unpredictable and should be avoided.
Suggested drugs:
Oral
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Isradapine: 0.1 mg/kg/dose q 6- 8h.
Hospital only. Will need to be changed to a different medication if patient
requires outpatient antihypertensive therapy.
NOT TO BE USED AS A MAINTENANCE MEDICATION
Labetalol: - See dosing table Appendix 2
Enalapril: - See dosing table Appendix 2
Intravenous
 Hydralazine: 0.15mg/kg iv q 3-4 hourly. Short acting rapid onset medication.
Should not be used as maintenance medication.
This can be given on the ward.
Longer acting drugs such as amlodipine, lisinopril may be started but will not provide acute control
of blood pressure
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Hypertensive Emergency
Defined as a severe elevation of blood pressure associated with a clinical picture of rapid and
progressive central nervous system, visual, myocardial, haematological or renal deterioration.
Fibrinoid necrosis of arterioles with retinal exudates and haemorrhages occur. Congestive heart
failure may occur, with infants being particularly prone to this complication.
There is no specific level of BP that constitutes a hypertensive emergency. It is defined as a blood
pressure high enough to cause acute injury to target organs
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Heart
Brain
Kidney
Eye
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left ventricular failure
hypertensive encephalopathy (9 - 33% of children)
renal failure
retinopathy
The most common causes in children are renal scarring from reflux nephropathy, and acute
nephritis. Children are more prone to hypertensive encephalopathy than adults, and you must
differentiate this from stroke or subarachnoid haemorrhage.
Management of the Hypertensive Emergency
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Admit the child to PICU.
Consult paediatric nephrologist and intensivist on call
Acute severe hypertension requires urgent treatment to prevent end organ damage. In chronic
severe hypertension, slow smooth BP reduction is strongly recommended. It is often difficult to
know whether hypertension is acute or chronic at the first presentation. Signs of end organ
damage are more likely in chronic hypertension (eyes, heart, kidney), and less likely to be present
in acute severe hypertension.
There is a high risk of neurological sequelae (spinal infarction, blindness) if anti-hypertensive drugs
cause a precipitous fall in blood pressure.
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Sublingual nifedipine is unpredictable and should be avoided if the duration of
hypertension is unclear and there are signs of end organ damage.
Reduce blood pressure urgently.
Secure IV access before commencing therapy
Monitor BP and pupillary responses frequently during therapy
Use continuous intra-arterial pressure monitoring. Dinamap is a second option in children aged
over 5 years
Aim to reduce blood pressure by one third of the total planned reduction in the first 24 hours,
and the remaining 2/3 over the next 48 to 72 hours
Formatted: Bullets and
Numbering
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The choice of intravenous antihypertensive drug is at the discretion of the treating physician.
These need to given in ICU.
o IV Labetalol: a bolus of 0.2 - 1 mg/kg, followed by a constant infusion (1 mg / ml in
0.9% NaCl). Begin infusion at 1 mg/kg/hour. Increase the infusion rate at 10 -15
minute intervals until there is an effect. If there is no effect at a dose of 2.5
mg/kg/hour, choose another agent.
o IV Sodium nitroprusside infusion (0.5-10micrograms/kg/min) may be used as a
second option. In this case, intra-arterial blood pressure monitoring is mandatory
o IV Hydralazine as per above
If BP falls too rapidly, give boluses of normal saline
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Avoid using ACE inhibitors until a renovascular cause has been excluded
Management of Primary Hypertension
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Weight reduction is the mainstay in obesity related hypertension.
Dietary modification with emphasis on sodium intake reduction is strongly encouraged in those
who have blood pressures in the prehypertensive range as well those with established
hypertension.
Lifestyle changes are integral to the successful treatment of hypertension.
Pharmacological therapy is indicated when primary interventions are unsuccessful. Single
agents which are suitable for daily dosing is preferred. Examples are ACE inhibitors, calcium
channel blockers,  blockers.
The goal for pharmacological therapy is reduction of blood pressure to <90% percentile.
Recommended Reading:
Goonasekera CDA, Dillon MJ. Measurement and interpretation of blood pressure. Arch Dis Child.
2000;82:261-265.
Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood in Children and
Adolescents Pediatrics. 2004;114:555-576.
de Man SA, André JL, Bachmann H, et al. Blood pressure in childhood: pooled findings of six
European studies. Journal of Hypertension. 1991;9:109-114.
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Appendix 1 – Table of Blood Pressure Levels for Age & Height
Adapted from The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents.
TABLE 1 BOYS. BP Levels for BOYS by Age and Height Percentile
Systolic BP
(mmHg)
Height percentile
Age
(years)
1
2
3
4
5
7
9
11
13
15
17
Author:
Editor:
Diastolic BP
(mmHg)
BP Percentile
5th
50th
95th
5th
Height percentile
50th
95th
50th
90th
95th
99th
80
94
98
105
85
99
103
110
89
103
106
114
34
49
54
61
37
52
56
64
39
54
58
66
50th
90th
95th
99th
84
97
101
109
88
102
106
113
92
106
110
117
39
54
59
66
42
57
61
69
44
59
63
71
50th
90th
95th
99th
86
100
104
111
91
105
109
116
95
109
113
120
44
59
63
71
46
61
65
73
48
63
67
75
50th
90th
95th
99th
88
102
106
113
93
107
111
118
97
111
115
122
47
62
66
74
50
65
69
77
52
67
71
79
50th
90th
95th
99th
90
104
108
115
95
108
112
120
98
112
116
123
50
65
69
77
53
68
72
80
55
70
74
82
50th
90th
95th
99th
92
106
110
117
97
111
115
122
101
115
119
126
55
70
74
82
57
72
76
84
59
74
78
86
50th
90th
95th
99th
95
109
113
120
100
114
118
125
104
118
121
129
57
72
76
84
60
75
79
87
62
77
81
89
50th
90th
95th
99th
99
113
117
124
104
117
121
129
107
121
125
132
59
74
78
86
61
76
80
88
63
78
82
90
50th
90th
95th
99th
104
117
121
128
108
122
126
133
112
126
130
137
60
75
79
87
62
77
81
89
64
79
83
91
50th
90th
95th
99th
109
122
126
134
113
127
131
138
117
131
135
142
61
76
81
88
64
79
83
91
66
81
85
93
50th
90th
95th
99th
114
127
131
139
118
132
136
143
122
136
140
147
65
80
84
92
67
82
87
94
70
84
89
97
Dr William Wong
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TABLE 2 - GIRLS:
BP Levels for Girls by Age and Height Percentile:
Systolic BP
(mmHg)
Age
(years)
1
2
3
4
5
7
9
11
13
15
17
Diastolic BP
(mmHg)
BP Percentile
5th
Height Percentile
50th
95th
5th
Height Percentile
50th
95th
50th
90th
95th
99th
50th
90th
95th
99th
83
97
100
108
85
98
102
109
86
100
104
111
88
101
105
112
90
103
107
114
91
105
109
116
38
52
56
64
43
57
61
69
40
54
58
65
45
59
63
70
42
56
60
67
47
61
65
72
50th
90th
95th
99th
86
100
104
111
89
103
107
114
93
106
110
117
47
61
65
73
49
63
67
74
51
65
69
76
50th
90th
95th
99th
88
101
105
112
91
104
108
115
94
108
112
119
50
64
68
76
52
66
70
77
54
68
72
79
50th
90th
95th
99th
89
103
107
114
93
106
110
117
96
109
113
120
52
66
70
78
54
68
72
79
56
70
74
81
50th
90th
95th
99th
93
106
110
117
96
109
113
120
99
113
116
124
55
69
73
81
57
71
75
82
59
73
77
84
50th
90th
95th
99th
96
110
114
121
100
113
117
124
103
116
120
127
58
72
76
83
59
73
77
84
61
75
79
87
50th
90th
95th
99th
100
114
118
125
103
117
121
128
107
120
124
131
60
74
78
85
61
75
79
87
63
77
81
89
50th
90th
95th
99th
104
117
121
128
107
121
124
132
110
124
128
135
62
76
80
87
63
77
81
89
65
79
83
91
50th
90th
95th
99th
107
120
124
131
110
123
127
134
113
127
131
138
64
78
82
89
65
79
83
91
67
81
85
93
50th
90th
95th
99th
108
122
125
133
111
125
129
136
115
128
132
139
64
78
82
90
66
80
84
91
68
82
86
93
* The 90th percentile is 1.28 SD, the 95th percentile is 1.65 SD, and the 99th percentile is 2.33 SD above the mean
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Appendix 2 – Neonatal Blood Pressure Values
Estimated BP values after 2 weeks of age in infants from 26 to 44 weeks postconceptional age
Reproduced with permission from Joseph Flynn (Pediatr Nephrol (2000) 14:332–341).
50th percentile
95th percentile
99th percentile
SBP
DBP
MAP
55
30
38
72
50
57
77
56
63
SBP
DBP
MAP
60
38
45
75
50
58
80
54
63
SBP
DBP
MAP
65
40
48
80
55
65
85
60
69
SBP
DBP
MAP
68
40
48
83
55
62
88
60
69
SBP
DBP
MAP
70
40
50
85
55
65
90
60
70
SBP
DBP
MAP
72
50
57
87
65
72
92
70
71
SBP
DBP
MAP
77
50
59
92
65
74
97
70
79
SBP
DBP
MAP
80
50
60
95
65
75
100
70
80
SBP
DBP
MAP
85
50
62
98
65
76
102
70
81
SBP
DBP
MAP
88
50
63
105
68
80
110
73
85
Post-conceptional
age
26 weeks
28 weeks
30 weeks
32 weeks
34 weeks
36 weeks
38 weeks
40 weeks
42 weeks
44 weeks
SBP = systolic blood pressure
DBP = diastolic blood pressure
MAP = mean arterial pressure
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Appendix 3 - Oral antihypertensive drugs for management of
hypertension in children 1-17 years old
Class
Drug
Dose
Frequency
Comments
ACE inhibitors
Captopril
Initial: 0.1-0.5mg/kg/dose
Max: 6mg/kg per day
Three times daily
Enalapril
Initial: 0.1mg/kg/day up to 5mg/day
Max: 1mg/kg/day up to 40mg/day
Initial: 0.1-0.2mg/kg/day up to 5mg/day
Initial: 0.7mg/kg/day up to 50mg/day
Max: 1.4mg/kg/day up to 100mg/day
Initial: 4mg/day
Max: 32mg/day
Initial: 4mg/kg/day in divided doses
Max: 20/kg/day up to 1200mg/day
Initial: 0.5-1mg/kg/day
Initial: 0.1-0.2mg/kg/day
Once or twice daily
Once daily
Liquid proprietary 5mg/ml
Liquid manufactured 1mg/ml. Requires
HEC for discharge if proprietary liquid not
available.
Liquid manufactured 1mg/ml
Liquid requires HEC for discharge
Round doses to tablet size, can halve
tablets. Soluble in water
Special authority required
Soluble in water.
Special authority required.
2 to 4 times daily
Once or twice daily
Once daily
Liquid requires HEC for discharge
Funded tablet does not disperse well,
use liquid if need part doses.
Extended release tablets, do not crush
Lisinopril
Angiotensinreceptor blocker
Losartan
Candesartan
 and -blocker
Labetalol
-blocker
Atenolol
Calcium channel
blocker
Amlodipine
(as mesylate)
Felodipine
Isradipine
Vasodilator
Minoxidil
Initial: 0.2mg/kg/day
Initial: 0.1mg/kg/dose
Once daily
Once daily
Once or twice daily
3 to 4 times daily
Initial: 0.1-0.2mg/kg/day
Max: 1mg/kg/day
Twice daily
Liquid manufactured 1mg/ml – switch to
alternative agent before discharge
Immediate release tablets are S29 –
unlicensed in NZ
Tablets can be crushed and dissolved
Not funded. Not licensed in NZ, can
supply from hospital via DCS
(discretionary community supply).
Should be used with a diuretic and blocker
Patients requiring more than one antihypertensive agent, or treatment with angiotensin receptor blockers (ARBs) or
minoxidil, should be discussed with a Paediatric Nephrologist.
Funding: All medicines listed above are fully funded as tablets/capsules unless specified. Availability of liquid formulations is listed where possible
with strength used at ADHB, including any additional funding requirements.
References:
Flynn JT. Neonatal hypertension: diagnosis and treatment. Pediatr Nephrol (2000) 14:332–341.
Kemp A, McDowell JM, editors. Paediatric Pharmacopoeia. 13th edition. Melbourne: Pharmacy Dept Royal
Children’s Hospital; 2002
Guy’s, St Thomas’ and Lewisham Hospitals. Paediatric formulary. 5th Edition. London: Guy’s and St Thomas’
Hospitals Trust; 1999.
Mehta DK, Exec editor. BNF for children 2007. London: British Medical Association and the Royal
Pharmaceutical Society of Great Britain; 2007
Strauser LM, Groshang T, Tobias JD. Initial experience with isradipine for treatment of hypertension in
children. Southern Medical Journal 2000; 93(3): 289-93.
Takemoto C, Hodding J, Krauss D. Pediatric Dosage Handbook 15th Edition; Lexicomp 2008
Author:
Editor:
Dr William Wong
Dr Raewyn Gavin
Service:
Reviewed:
Nephrology
December 2009
Page:
12 of 13
The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and
Adolescents, Pediatrics. 2004; 114: 555-576
Author:
Editor:
Dr William Wong
Dr Raewyn Gavin
Service:
Reviewed:
Nephrology
December 2009
Page:
13 of 13

HYPERTENSION (Blood Pressure in Childhood) Starship Children’s Health Clinical Guideline

Transcription

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